9.4 Geographical Disparities

Factors Influencing Population Health Related to Location

The 2022 National Healthcare Quality and Disparities Report compares health care quality and disparities scores on over 100 health-related measures among states (AHRQ, 2022), with the following results:

• Best overall health care quality: Maine, Massachusetts, New Hampshire, Pennsylvania, Rhode Island, Iowa, Minnesota, North Dakota, Wisconsin, Colorado, and Utah
• Lowest overall health quality: Alaska, Arizona, California, Montana, Nevada, New Mexico, Wyoming, Washington D.C., Georgia, Mississippi, Oklahoma, Texas, and New York
• Fewest racial and ethnic disparities overall: Arizona, Hawaii, Idaho, Oregon, Washington, Arkansas, Kentucky, Virginia, West Virginia, Kansas, and New Jersey
• Most racial and ethnic disparities overall: Connecticut, Massachusetts, New York, Pennsylvania, Illinois, Minnesota, Ohio, Washington D.C., North Carolina, and Texas

There are several reasons for variations among states in terms of health care quality and disparities (AHRQ, 2022). First, health policy can vary by state. Some states may offer more health-related resources or social programs than others. Health care delivery infrastructure can vary by state. For example, some states regulate the construction of new hospitals and other treatment facilities more closely. Finally, disease prevalence can vary by state. For example, diabetes, arthritis, and chronic obstructive pulmonary diseases are more prevalent in eastern U.S. states (Raghupathi & Raghupathi, 2018). Diabetes, in particular, is influenced by cultural, behavioral, and environmental factors associated with certain geographical areas (Zang et al., 2021); it is more prevalent in the southeastern and Appalachian portions of the United States (CDC, 2022a). Asthma is another disease with some geographical trends, although a lot of variation related to population density and demographics can exist in a particular state. The Northeast Mid-Atlantic asthma belt (from Greensboro, North Carolina, to Boston, Massachusetts) has been shown to have a higher prevalence of asthma possibly due to poverty, poor air quality, and less access to specialists (Pate et al., 2021). The Asthma and Allergy Foundation of America (2018) identified a second group of states with an increased prevalence of asthma and associated ED visits and deaths. The Ohio-Lake Erie asthma belt spans from Louisville, Kentucky, to Detroit, Michigan.

Health and related outcomes vary not only by state, but also by county, town, or zip code. Research has linked zip codes to health outcomes (Holmes et al., 2018). For example, people living in neighborhoods with limited access to healthy foods and safe areas to exercise are at higher risk for health problems.

Factors Influencing Population Health Related to Population Density

Some of the most common geographical disparities exist between those who live in rural areas and those who live in urban areas. Individuals living in rural areas face geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, limited access to health care specialists and subspecialists, and limited job opportunities (Rural Health Information Hub [RHIH], 2023). Additionally, residents who live in rural areas are less likely to be employed by organizations that provide health insurance coverage. If individuals living in rural areas also live below the poverty level, they are less likely to be covered by Medicaid (RHIH, 2023). Rural health disparities are often caused by access to health care and public health services, socioeconomic status, health behaviors, and health insurance status. Rural Americans are at a greater risk of death from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than Americans who live in urban areas (RHIH, 2022). Rural residents tend to be older and more obese and to have more health problems than urban residents. They are more likely to smoke cigarettes and are less likely to use seat belts (Figure 9.5) (FDA, 2021). Table 9.3 presents relevant factors affecting rural health outcomes.

Figure 9.5 National efforts to promote the use of seat belts include public information campaigns, such as this valentine-themed graphic from the National Transportation and Safety Board. Studies have shown that residents of rural areas are less likely to wear seat belts than residents of urban areas, which is one factor contributing to higher traffic fatality rates in rural areas (CDC, 2017). (credit: “NTSB Valentine” by National Transportation Safety Board/Flickr, Public Domain)